Form 28 Request for Information

OMB No. 1651-0023
Exp. 03-31-2014

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

1. Date of Request

REQUEST FOR INFORMATION

2. Date of Entry and Importation

19 CFR 151.11

3. Manufacturer/Seller/Shipper

4. Carrier

5. Entry No.

5a. Invoice Description of Merchandise

5b. Invoice No.

7. Country of Origin/Exportation

8. CBP Broker and Reference or File No.

9. TO:

10. FROM:

11a. Port

Production of Documents and/or Information Required by Law: If you
have provided the information requested on this form to U.S. Customs and
Border Protection at other ports, please indicate the port of entry to which it
was supplied, and furnish a copy of your reply to this office, if possible.

General Information and Instructions on Reverse
12. Please Answer Indicated Question(s)
A.

B.

6. HTSUS Item No.

11b. Date Information
Furnished

13. Please Furnish Indicated Item(s)

Are you related (see reverse) in any way to the seller of
this merchandise? If you are related, please describe the
relationship, and explain how this relationship affects the
price paid or payable for the merchandise.

Identify and give details of any additional costs/
expenses incurred in this transaction, such as:

A.

Copy of contract (or purchase order and seller's
confirmation thereof) covering this transaction, and any
revisions thereto.

B.

Descriptive or illustrative literature or information
explaining what the merchandise is, where and how it is
used, and exactly how it operates.

C.

Breakdown of components, materials, or ingredients by
weight and the actual cost of the components at the time
of assembly into the finished article.

D.

Submit samples:
Article number and description

(1) packing

from container

(2) commissions

mark(s)and number

(3) proceeds that accrue to the seller
(4) assists
(5) royalties and/or license fees

E.

Samples consumed in analysis, and other samples whose
return is not specifically requested, will not normally be
returned.
See item 14 below.

14. CBP Officer Message

15. Reply Message (Use additional sheets if more space is needed.)

16.
CERTIFICATION

It is required that an appropriate corporate/company official execute this certificate and/or endorse all correspondence
in response to the information requested. (NOTE: NOT REQUIRED IF FOREIGN FIRM COMPLETES THIS FORM.)

I hereby certify that the information
furnished herewith or upon this form in
response to this inquiry is true and correct,
and that any samples provided were taken
from the shipment covered by this entry.

17. CBP Officer

16a. Name and Title/Position of Signer (Owner, l6b. Signature
Importer, or Corporate/Company Official)
16c. Telephone No.
18. Team Designation

16d. Date

19. Telephone No.
CBP Form 28 (03/11)

GENERAL INFORMATION AND INSTRUCTIONS
1.

The requested information is necessary for proper classification and/or appraisement of your merchandise and/or for insuring
import compliance of such merchandise. Your reply is required in accordance with section 509(a), Tariff Action of 1930, as
amended (19 U.S.C. 1509).

2.

All information, documents, and samples requested must relate to the shipment of merchandise described on the front of this
form.

3.

Please answer all indicated questions to the best of your knowledge.

4.

All information submitted will be treated confidentially.

5.

If a reply cannot be made within 30 days from the date of this request or if you wish to discuss any of the questions designated
for your reply, please contact the CBP officer whose name appears on the front of this form.

6.

Return a copy of this form with your reply.

DEFINITIONS OF KEY WORDS IN BLOCK 12

Question A: RELATED - The persons specified below shall be treated as persons who are related:
(A) Members of the same family, including brothers and sisters (whether by whole or half blood), spouse,
ancestors, and lineal descendants.
(B) Any officer or director of an organization and such organization.
(C) An officer or director of an organization and an officer or director of another organization, if each such
individual is also an officer or director in the other organization.
(D) Partners.
(E) Employer and employee.
(F) Any person directly or indirectly owning, controlling, or holding with power to vote, 5 percent or more of the
outstanding voting stock or shares of any organization and such organization.
(G) Two or more persons directly or indirectly controlling, controlled by or under common control with, any person.
PRICE PAID OR PAYABLE - This term is defined as the total payment (whether direct or indirect and exclusive of any costs,
charges, or expenses incurred for transportation, insurance, and other C.I.F. charges) made, or to be made, for imported
merchandise by the buyer to, or for the benefit of, the seller.
Question B:

ASSISTS - The term "assist" means any of the following if supplied directly or indirectly, and free of charge or at
reduced cost, by the buyer of the imported merchandise for use in connection with the production or the sale for
export to the United States of the merchandise:
(1) Materials, components, parts, and similar items incorporated in the imported merchandise.
(2) Tools, dies, molds, and similar items used in the production of the imported merchandise.
(3) Merchandise consumed in the production of the imported merchandise.
(4) Engineering, development, artwork, design work, and plans and sketches that are undertaken elsewhere than in
the United States and are necessary for the production of the imported merchandise.

PROCEEDS THAT ACCRUE TO THE SELLER - This term is defined as the amount of any subsequent resale, disposal, or use of
the imported merchandise that accrues, directly or indirectly, to the seller.
ROYALTIES AND/OR LICENSE FEES - This term relates to those amounts that the buyer is required to pay, directly or
indirectly, as a condition of the sale of the imported merchandised for exportation to the United States.
PAPERWORK REDUCTION ACT STATEMENT - An agency may not conduct or sponsor an information collection and a person is
not required to respond to this information unless it displays a current valid OMB control number and an expiration date. The control
number for this collection is 1651-0023. The estimated average time to complete this application is 2 hours. If you have any
comments regarding the burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings,
799 9th Street, NW., Washington DC 20229.

CBP Form 28 (03/11)(Back)